Aspects nutritionnels des hépatopathies chroniques stables

Patients with chronic liver disease are often malnourished, and the provision of adequate nutritional support is essential to help minimize its detrimental effects on clinical outcome. Certain complications of chronic liver disease, such as fluid retention, are managed with dietary manipulation or restriction, but this should not be at the expense of the adequacy of the diet as a whole. It is, therefore, essential that nutritional status is assessed in this patient population not only at presentation but also at long-term intervals. A reasonably reliable assessment can be made by combining data from clinical and dietary histories, the physical examination and an anthropometric evaluation. With such information, feeding can be targeted and optimized on an individual basis. The inclusion of nutritional management in the mainstream rather than the periphery of patient care is essential.     

Rôle du foie dans le métabolisme des nutriments en nutrition artificielle

The liver is a prominent organ in nutritional homeostasis. Due to unique metabolic properties, it plays a main role in the metabolism of the three macronutrients ‘as well as the micronutrients’ (vitamins and minerals) storage. Although it represents only 2.5% of the body mass, it consumes 20% of total resting energy expenditure and a similar percentage of the amino acid mixture absorbed via the gut during and after a meal. Due to a peculiar vascularization (portal vein, the entire gastrointestinal venous flux is directed towards the liver with all hydrosoluble nutrients, only water-unsoluble lipids being excluded from this obligatory ‘first-pass mechanism’). Since it is the location for glycogen storage, VLDL synthesis and ketogenesis, the liver is crucial in the fed-to-fasted metabolic alternation. While fat is not physiologically stored in the liver, it is a very important organ in lipid metabolism. Except immunoglobulins, all plasma proteins are synthetised by the liver together with the constitutive proteins, explaining that it is a very powerful organ for protein synthesis. Finally, due to a very active amino acid metabolism, the liver can reshape the amino acid-mixture coming from the gut in the absorptive state. Such a phenomenon has a major implication in the nutritional physiology of amino acid metabolism according to the route: enteral or parenteral. Indeed, in the latter case the remodelling by the liver does not occurs.     

Prise en charge nutritionnelle à domicile des malades cancéreuxHome artificial nutrition in cancer patients

Cancer is the first indication for home artificial nutrition in France, with rising figures. Survival of cancer patients on home parenteral nutrition is lower than that of other patients on home parenteral nutrition, due to the evolution of the underlying disease, and cancer is also associated with lower survival figures in home enteral nutrition patients. More than half of cancer patients die within the first year of home artificial nutrition. Home artificial nutrition seems to improve health-related quality of life, and may improve life expectancy in some patients. It is prescribed in patients during treatment (supportive care) or with therapeutic sequels, the indications being comparable to those in the hospital setting. Home artificial nutrition as a palliative care is much more debated, as it has not proved to increase quality of life or survival. It should be banned for patients with a life expectancy lower than three months and a Karnofsky index lower than 50. There is no specific nutrition technique for cancer patients.     

Home Artificial Nutrition in Polish Children: An Analysis of 9-Year National Healthcare Provider Data

Background: Home artificial nutrition (HAN) is a developing method of treatment that reduces the need for hospitalizations. The epidemiology of pediatric HAN in Poland has not yet been covered in detail. This study is a longitudinal nationwide analysis of incidence, prevalence, and patients’ profile for HAN in Polish children. Methods: Assessment of National Health Fund (NFZ) data covering all pediatric patients treated with HAN in Poland between 2010 and 2018. Results: HAN was received by 4426 children, 65 patients were on home enteral nutrition (HEN) or home parenteral nutrition (HPN) at different times (HEN n = 3865, HPN n = 626). HAN was most frequently started before the child was 3 years old and long-term HAN programs (5–9 years) were reported. The most common principal diagnosis in HEN was food-related symptoms and signs. In HPN, it was postoperative gastrointestinal disorders. A regionally differentiated prevalence of HAN patients and centers was demonstrated. Mortality among patients was 24.9% for HEN, and 9.6% for HPN, and the main in-hospital cause of death was cardiac arrest. Conclusions: HAN’s use is increasing and evolving in Poland. Uneven distribution of patients and centers results in difficult access to the nutritional procedure which, together with the increasing number of patients, highlights the need for data analysis and development of nutrition centers.     

Éléments traces, stress oxydant et hépatopathies alcooliques

Marked disorders in trace-element homeostasis occurred following various experimental conditions of ethanol administration. A decrease in zinc, copper and selenium, and an increase in non-heme iron are often observed at the hepatic level. Some of these alterations may contribute to collagen accumulation and to the decrease in the major enzymatic antioxidants such as superoxide dismutase (Cu, Zn-SOD) and glutathion peroxidase (Se-GPx). The decrease in the antioxidant defense associated with the increase in the low molecular weight non-heme iron complexes or redox active iron, a pro-oxidant factor, may play a prominent role in the occurrence of oxidative stress, which leads to enhanced lipid peroxidation. The severity of inflammatory and fibrotic disorders, which has been reproduced in rats by long-term ethanol administration associated with a high fat diet, is correlated to the intensity of oxidative stress. Clinical studies report alterations in trace elements and in some parameters of oxidative stress in patients suffering from alcohol-dependent liver disease. Supplementation with selenium and/or zinc may be considered in the prevention of the progressive alcoholic liver injury.     

Hépatopathies métaboliques congénitales — Recommandations pour la prise en charge nutritionnelle

Many hereditary errors of metabolism may cause hepatopathy in children. In most cases, treatment is mainly or exclusively based on dietetics. Management of acute hepatopathy must take into account the possible metabolic origin, and urgent diet adaptations have to be begun until a metabolic disease has been excluded. If a metabolic disease is diagnosed, therapeutic strategies, whether to limit the accumulation of toxic compounds above the metabolic block (as in galactosemia, tyrosinemia type I, congenital hyperammonemias) or to compensate deficient compounds below the enzymatic block (as in glycogenosis, gluconeogenesis defects, fatty acid oxidation defects), have to be undertaken. In this paper we discuss dietary therapy principles in hereditary errors of metabolism that give rise to hepatopathies. These dietetic strategies have to cope with the nutritional needs of the child for growth and development. They have to be realistic enough to be accepted in the long term (whole life) by the child and his family. Diet therapy is a complex treatment and has to be rigorously managed by experienced doctors and dieticians.     

Rôle des acides gras alimentaires dans la physiopathologie des hépatopathies alcooliques

Many experimental studies in animals suggest that dietary fat plays an important role in the pathogenesis of alcoholic liver disease. Polyunsaturated fatty acids potentiate alcohol-induced liver injury at least in part by inducing cytochrome P450 2E1, cyclooxygenase-2 and lipid peroxydation. On the other hand, dietary saturated fatty acids reduce steatosis, necrosis, inflammation and fibrosis in conjunction with decreased expression of TNF-α and cyclooxygenase-2, and reduce lipid peroxidation. Dilinoleoyl-phosphatidylcholine prevents alcohol-induced fibrosis and cirrhosis in baboons and stimulates collagenase activity in cultured lipocytes. There are few human studies which confirm these experimental results. Epidemiological studies suggest a relationship between daily fat intake, particularly dietary polyunsaturated fatty acids, and the risk of liver cirrhosis in alcoholics. The studies having demonstrated that being overweight is a risk factor of alcoholic cirrhosis and that the apolipoprotein E polymorphism influences the severity of liver injury in alcoholic cirrhotics strongly favor the role of fatty acids in the pathogenesis of human alcoholic liver disease.     

Complications hépatiques de la nutrition artificielle chez l'enfant : stratégies thérapeutiques

Parenteral nutrition-associated complications in children can result in the deterioration of hepatic structure and function which ultimately leads to cirrhosis. The frequency and prevalence of these complications are difficult to clarify; moreover, their presentation is polymorphous (lithiasis, steatosis, cholestasis, fibrosis) and nonspecific. Patients at risk need to be clearly identified, since preventive intervention and treatment can slow down the disease's progression. However, when intestinal functions become severely impaired with absolute dependency on parenteral nutrition, intestinal transplantation becomes the sole treatment.     

Nutrition au cours des radiothérapies et chimiothérapiesNutritional support during cancer chemotherapy and radiotherapy

Nutritional support for cancer patients treated with radiotherapy and chemotherapy are strongly requested with regard to the frequent malnutrition at time of diagnosis. Furthermore, the malnutrition often progresses with adverse effects of therapy and disease progression. Nutritional screening and assessment are essential. Dietetic care is mandatory for patients with malnutrition or at risk of malnutrition when they are still able to eat. But this oral nutritional support is frequently unable to maintain sufficient nutritional intakes with regard to tumour effect or treatment toxicity. Enteral or parenteral nutrition must be provided to patients unable to absorb adequate quantity of nutrients for a prolonged period. The primary goal is to avoid, especially for malnourished patients, further nutritional degradation which can lead to treatment interruptions, complications or increased risk of death. Routine administration of artificial nutrition has been tested during radiotherapy and chemotherapy but results are conflicting and data are missing for severely malnourished patients. No benefits in terms of treatment toxicity, tumour response, risk of complications and finally mortality have been demonstrated for routine use of artificial nutrition. Most decisions for indication of nutritional support, route of administration and quality of artificial nutrition in this field can't rely today on evidence-based medicine. However, artificial nutrition can provide nutrients and hydration necessary to maintain comfort and to improve survival for patients unable to eat sufficient nutrition for a prolonged period.     

Proceedings of the 2016 Clinical Nutrition Week Research Workshop—The Optimal Dose of Protein Provided to Critically Ill Patients

Recent literature has created considerable confusion about the optimal amount of protein/amino acids that should be provided to the critically ill patient. In fact, the evidentiary basis that directly tries to answer this question is relatively small. As a clinical nutrition research community, there is an urgent need to develop the optimal methods to assess the impact of exogenous protein/amino acid administration in the intensive care unit setting. That assessment can be conducted at various levels: (1) impact on stress response pathways, (2) impact on muscle synthesis and protein balance, (3) impact on muscle mass and function, and (4) impact on the patient's recovery. The objective of this research workshop was to review current literature relating to protein/amino acid administration for the critically ill patient and clinical outcomes and to discuss the key measurement and methodological features of future studies that should be done to inform the optimal protein/amino acid dose provided to critically ill patients.     

Enquête auprès des associations d’aide alimentaire (E3A) : mode de fonctionnement des structures et valeur nutritionnelle des colis et repas distribués

The E3A survey was conducted in 2003-2004 among food aid charities in France to investigate the difficulties faced by these organizations and to estimate the nutritional quality of delivered food aid. On average, meals and food baskets provided 850 and 800 kcal/d, respectively. Although delivered meals had an acceptable nutritional quality, food baskets had a high energy density (160 kcal/100g) and low nutrient densities. The nutritional quality of food baskets prepared in advance did not differ from that of baskets constituted by food aid recipients themselves in social grocery-stores. The nutritional quality was not better in organizations where volunteers had declared having taken into account dietary balance when designing food baskets. This suggests that dietary recommendations are unknown and / or difficult to put into practice in this context. To improve the nutritional status of the most vulnerable populations in France, access to a balanced diet should be facilitated, in particular by giving charities the means of delivering food aid of good nutritional quality.     

Stratégies de prise en charge nutritionnelle spécifiques : l'enfant et l'adulte jeune atteints d'un handicap

Handicapped children are at high risk for malnutrition. In this situation nutritional assessment becomes difficult to perform due to musculo-skeletal deformities, patient's collaboration. In any case nutritional indices require simple measures: weight and height. Nutritional care must be presented early to parents in order to start as soon as possible when oral intake does not meet nutritional needs. For the handicapped child, surgery is often a major stress that requires nutritional care before, during and after. Obesity often aggravates the burden of the handicap and does not provide protection against malnutrition. Like in non-handicapped persons nutritional care can improve the outcome and well being of handicapped children.     

Nutritional Treatment in Crohn’s Disease

Crohn’s disease (CD) is a chronic inflammatory bowel disease (IBD) which can affect any part of the whole gastrointestinal tract (from mouth to anus). Malnutrition affects 65–75% of CD patients, and it is now well acknowledged that diet is of paramount importance in the management of the disease. In this review, we would like to highlight the most recent findings in the field of nutrition for the treatment of CD. Our analysis will cover a wide range of topics, from the well-established diets to the new nutritional theories, along with the recent progress in emerging research fields, such as nutrigenomics.     

Manifestations digestives et nutritionnelles des déficits immunitaires congénitaux et acquis chez l'enfant

The gastrointestinal and nutritional impact of congenital immunodeficiencies is varied and non-specific (serious refractory diarrhea, exsudative enteropathy, enterocolitis and chronic infections by Cryptosporidium, Giardia, rotavirus, Candida, etc.). Ulcerative colitis and autoimmune diseases are less frequent. Available therapeutic tools (immunoglobulins, implantable venous accesses and BMT) are reasonably effective. AIDS in children can be either rapidly or slowly progressive, and is usually due to maternofetal transmission. Gastrointestinal lesions are non-specific (candidiasis, chronic malabsorptive diarrhea, hepatitis, cryptosporidiosis, CMV, giardiasis, herpes) and cause overall malnutrition. Early nutritional support is indicated, but the modalities and results remain to be determined.     

Dénutrition périnatale : prise en charge nutritionnelle spécifique du nouveau-né

Malnutrition is quite rare in neonates. However perinatal malnutrition occurs in two situations. Fetal malnutrition leading to intra-uterine growth retardation with a birth weight below the lower limit for gestational age. On the other hand a postnatal relative malnutrition ("extra-uterine" growth retardation) which occurs mainly in preterm neonates. Both these situations need specific nutritional care after birth but also during the first years of life as there is probably a relationship between post-natal nutrition and health in adults (Barker hypothesis).     

Évaluation de l'état nutritionnel et des besoins de l'enfant et de l'adolescent

Ten to fifteen percent of hospitalized children suffer from malnutrition. Children suffering from chronic diseases are at particularly high risk for malnutrition. A systematic screening for malnutrition and nutritional risk can improve nutritional care in this population. Simple measures (weight and height at admission) can be used to calculate nutritional indices (weight for height ratio or body mass index). Nutritional risk depends on: 1) the severety of the principal diagnosis, 2) the ability to feed oneself, and 3) the pain intensity. The oral or enteral route is preferred when the gut is functional. In all cases nutritional status must be followed throughout hospitalisation. Furthermore, it is preferable to begin nutritional care before malnutrition sets in. Nutritional care can improve the outcome and well-being of hospitalized children.